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October 2011Volume 37 Number 10
The Joint Commission Journal on Quality and Patient Safety
James W. Pichert, Ph.D.; Ilene N. Moore, M.D., J.D.; Gerald B. Hickson, M.D.; Vanderbilt University Medical Center,
Nashville, Tennessee. Please address correspondence to James W. Pichert, jim.pichert@Vanderbilt.Edu.
Mount Sinai Medical Center obstetrics service’s process to ad-
dress unprofessional behavior.1This important article models the
kind of action research needed for health care organizations to
address threats to patient safety and promote a culture of safety.
Also, to our knowledge it is the first to provide the numbers of
submitted staff reports about problematic behavior and to de-
scribe the types of issues reported and the subsequent actions
Safety cultures emerge as organizations dually address systems
failures and unacceptable performance.2Keys to success mirrored
by the Mount Sinai experience include the following:
■ Values and goals:The professionalism program is anchored
in a Code of Professionalism endorsed by physician, nursing,
and union leadership.
■ Leadership: Obstetrics’ leadership is committed to partici-
pate in the process and apply the same behavioral expectations
to all team members irrespective of title.
■ Readiness to address systems and behavior: Implementation
included staff education and dialogue about the program’s align-
ment with shared quality and safety goals.
■ “Learning systems” that alert leaders about threats to safety:
The workforce is taught how to report, and nonretaliation is as-
sured for reporting in good faith.
■ Key persons well trained to achieve goals, address systems issues,
and hold individuals accountable: Code of Professionalism com-
mittee members are accountable for review and follow-up on all
■ Methods and procedures to analyze events, identify patterns,
and execute improvement plans: Criteria for review and specified
action yield consistent responses for holding individuals account-
able and addressing systems issues.
■ Metrics: The professionalism program’s progress is moni-
tored via analysis of reports and safety culture survey data.
Professionalism and peer accountability are essential to a
safety culture.3Obstetrics service members are encouraged to re-
port concerns so that review, intervention, and feedback can
n “Professionalism: A Necessary Ingredient in a Culture of
Safety, ” DuPree and colleagues describe outcomes of the
occur. Increased report numbers likely reflect comfort in “speak-
ing up” and confidence that reports will be addressed fairly.
Vanderbilt’s professionalism program first focused on physi-
cian behavior and peer-delivered interventions,4which estab-
lished credibility with other professionals. All physicians, staff,
and students are subject to a Professional Conduct policy. In ad-
dition, we engage entire departments in morbidity, mortality,
and improvement conferences to identify and address systems
issues,2,5and our intervention process2,4also promotes sys-
temwide behavior change (for example, in hand hygiene).6
Issues and questions for further research remain. What
methodologies might reliably identify system weaknesses that
contribute to performance issues? Are coworker reports codable?
Are trends identifiable? Of note, only the obstetrics service at
Mount Sinai currently employs the Code of Professionalism and
feedback program. If unprofessional behavior is addressed differ-
ently across an organization, the programs may be unsustainable
and invite legal risk. How might inpatient/outpatient unit “fam-
ilies” of providers and support staff disseminate their successes so
that the institution adopts the program? Future studies must seek
to identify best practices for managing coworker reports of, re-
sponses to, and remediation performance and systems issues. We
salute the Mount Sinai team for taking on the challenge and re-
porting their data. We look forward to their and others’ contin-
ued contributions to making health care kinder and safer.
1. DuPree E., et al.: Professionalism: A necessary ingredient in a culture of safety.
Jt Comm J Qual Patient Saf 37:447–455, Oct. 2011.
2. Hickson G.B., et al.: Balancing systems and individual accountability in a
safety culture. In Joint Commission Resources (JCR): From Front Office to Front
Line: Essential Issues for Health Care Leaders, 2nd ed. Oak Brook, IL: JCR, forth-
3. Hickson G.B., Entman S.S.: Physicians influence and the malpractice problem.
Obstet Gynecol 115:682–686, Apr. 2010.
4. Hickson G.B., et al.: A complementary approach to promoting professionalism:
Identifying, measuring, and addressing unprofessional behaviors. Acad Med
82:1040–1048, Nov. 2007.
5. Deis J.N., et al.: Transforming the morbidity and mortality conference into an in-
strument for systemwide improvement. U.S. Agency for Healthcare Research and
Quality: Advances in Patient Safety: New Directions and Alternative Approaches, 2005.
6. Johnson J.G., et al.: Using financial incentives to improve hand hygiene adherence.
Poster presented at the 21st Annual Scientific Meeting, Society for Healthcare Epi-
demiology in America, Dallas, Apr. 2, 2011.
Professionals Promoting Professionalism
Copyright 2011 © The Joint Commission